Tag Archives: Substance Abuse & Addictions

Substance Abuse & Addictions

Opioid SOS

By Laurie Meyers May 31, 2017

During a single afternoon this past August, 26 people overdosed on opioids in Huntington, a small city in West Virginia with a population of approximately 50,000. Bolstered by naloxone — an opioid antidote that often can revive overdose victims who have stopped breathing — and too much practice in overdose scenarios, police and paramedics were able to save all 26 people. However, the danger of overdosing is so great — and so common — that many of those 26 individuals are likely to overdose again, some fatally.

Scenes of opioid overdoses are playing out again and again in cities, towns and rural areas across the United States. So many Americans are in thrall to opioids — which encompass both prescription pain relievers and the illegal drug heroin — that the Centers for Disease Control and Prevention (CDC) has declared opioid abuse an epidemic. According to the CDC, in 2015 (the latest year data were collected) more than 33,000 Americans died from opioid overdoses, a number that is quadruple the rate of deaths in 1999. In fact, from 2000 to 2015, more than half a million deaths were attributed to opioid overdose. West Virginia, New Hampshire, Kentucky, Ohio and Rhode Island are the states with the highest rates of opioid deaths, but no state, no socioeconomic status and no racial or ethnic group can claim to remain untouched by the opioid epidemic.

“We’re in danger of losing a generation,” asserted Carol Smith at an April congressional briefing on Capitol Hill sponsored by the American Counseling Association to raise awareness about the opioid epidemic and the role professional counselors can play in stemming the tide. Smith, a member of ACA and a past president of the West Virginia Counseling Association, is a counseling professor and the coordinator of the violence, loss and trauma certificate of studies at Marshall University — which happens to be located in Huntington.

Birth of an epidemic

The CDC numbers show that the opioid epidemic has been gathering steam for a long time. Public awareness of the epidemic has grown gradually with media reports of more fatal overdoses, including the startling 2016 death of music legend Prince by overdose from nonprescribed fentanyl. More than a year later, the full story is not yet known, but the singer and musician had reportedly been taking prescription opioids for chronic pain for many years, which put him at risk for developing an addiction.

In fact, for many of the people who become addicted to opioids, this is how it begins — with a prescription for painkillers. According to the CDC, prescriptions for opioids in the U.S. have quadrupled since the year 2000, despite there being no corresponding overall increase in the amount of pain that Americans report. Experts say a combination of factors has driven the sharp rise in opioid prescriptions. In the late 1990s, in a push to improve pain management, the medical community began considering pain a fifth vital sign, along with body temperature, pulse rate, respiration rate and blood pressure. The prescription drug OxyContin debuted in 1996 and was marketed as less addictive than other opioids. Research that has since been discredited asserted that patients in severe pain had a low tendency to become addicted to opioids.

“That was simply not true,” says Kirk Bowden, a licensed professional counselor (LPC) and ACA fellow in Phoenix who has specialized in addictions for almost 30 years. “They found that [severe pain] patients did start to become addicted — very early on. You can become addicted even if you follow the physician’s directions.”

Experts say that certain populations are particularly at risk for becoming addicted to opioids, including individuals who have a history of trauma, mental illness or other substance abuse. Medical professionals such as doctors, nurses, dentists and veterinarians are at increased risk because they have easy access to opioids through their work. Those in the military are also at greater risk because they are so often treated for pain.

As Smith points out, opioids are particularly addictive because of the effect they have on a person’s mind and body. “We are all biologically vulnerable,” she says.

Opioids attach to opioid receptors in the body to reduce the sensation to pain. As they do this, they cause physical changes in the body’s own opioid system. Over time, the body may become physically dependent on opioids. Even a weeklong prescription for opioids can cause withdrawal at cessation. In addition, opioids affect the brain’s reward system and can cause a feeling of euphoria. This combination of effects means that long-term use is itself a risk factor for physical dependence and addiction. A study reported in the March 17 issue of the CDC’s Morbidity and Mortality Weekly Report found that in patients prescribed opioids for the first time, the likelihood of them still being on the opioid within a year’s time increased after just six days of use and then again at 31 days.

Unfortunately, Smith Says, doctors and dentists commonly prescribe 30-, 60- or 90-day supplies of opioids to help patients alleviate instances of even short-term pain, such as the removal of wisdom teeth.

Some people who become addicted while on painkillers turn to heroin once their prescription runs out or when other opioids become too expensive, says ACA member Kevin Doyle, an LPC who has a private practice that specializes in group work for clients who have substance use disorders. It is becoming more common for heroin to be mixed with fentanyl, which is a much stronger opioid. Frequently, he notes, users either don’t know about the fentanyl or misjudge the dose and end up overdosing.

Addiction as a lifelong illness

There is a common misconception, not just on the part of the average person but also by many health professionals, that “getting sober” (clearing the body of the addictive substance) and recovery are the same thing. Nothing could be further from the truth, say substance abuse experts.

All of the counseling professionals interviewed for this article say that the standard for addiction treatment for both inpatient and outpatient programs is typically 30 days to get biologically clean. Clients are then sent back into their home environments, where they can easily become addicted again in the absence of follow-up support.

“You hear numbers about treatment programs that have outrageous treatment success rates, like 98 percent, but they don’t say where people are five years later,” Bowden notes. “People new to [addiction and recovery] don’t realize how addiction encompasses your whole life. … Long-term support is critical.”

ACA member Larry Ashley, an LPC with more than 40 years in the field of addictions, agrees. He says that as hard as getting “sober” or physically clean may be, it is actually the easiest part of recovery. “Recovery is a lifestyle change,” he says. “It’s important that people understand the difference between sobriety and recovery.”

Smith adds that addiction is most often treated like an acute disease when it is actually a chronic one, and the challenges don’t just stem from staying off the substance.

Doyle agrees. “There is a tendency to think of this [addiction treatment] as a single episode — that once you take care of that, we are done,” he says. “But, unfortunately, it’s a lifelong disease, and like any other disease, there may be episodes when a person doesn’t take as good of care of themselves as [other times]. I tell the client upfront, ‘We don’t see a cure, but this is something that can be managed.’”

The cost of not seeking help for addiction is high, and the opioid epidemic has been particularly devastating. ACA member Rick Carroll, a counselor who helped develop the substance abuse certification program at Lindsey Wilson College, has seen many people lose everything to opioids. And like a bomb blast, the destruction from addiction is not limited to the person hooked on opioids — it spreads outward.

In fact, the fallout from opioid abuse is what spurred the state of Kentucky, where the main campus of Lindsey Wilson College is located, to fund Carroll’s certification program. Currently, 1 in 4 babies born in Kentucky is diagnosed with neonatal abstinence syndrome — a range of physical problems that result from being exposed to opioids in the womb. The babies and mothers receive any needed addiction treatment and health care at the hospital, but there is also a need for clinicians who can help mothers cope with bonding and other family issues while undergoing detox.

Carroll also does parental assessments in Virginia for social services and the local court system. He sees many parents who have lost their children to foster care because of opioid abuse and estimates that a third of these clients will never regain custody of their children.

Many problems associated with addiction cannot be addressed with a 30-day program because recovery involves rebuilding a life, say the counselors interviewed for this article. In many instances, these clients have a lot to “relearn,” Carroll says.

“In our program, we talk about meeting people where they are at,” he says. “Which stage of change are they in? Do they say that they have a [substance abuse] problem? Where are they in recognizing the problem?”

People often take substances such as opioids as a way to cope, so counselors can help these clients by teaching them healthy coping skills, Carroll says. This starts by teaching them to be mindful and pay attention to their emotions, particularly becoming aware of when they are experiencing negative emotions such as anxiety and depression. Journaling can be helpful as a kind of daily log of thoughts and feelings, says Carroll, adding that some clients feel more connected to their emotions when they write them down.

As clients learn to be mindful of their emotions, they also need to be presented with new ways to cope, Carroll says. Among the tools he shares with clients are relaxation techniques and systematic desensitization. Carroll says that counselors should talk to clients about the events and everyday situations that are most stressful for them and have them practice breathing and other relaxation techniques that they can continue to use on their own. Counselors can also teach clients how to better deal with conflict through role-play and empty chair exercises, he says.

People who struggle with addiction are also often dealing with significant cognitive distortions, such as thinking that they are damaged goods, Carroll explains. Counselors can help clients examine these beliefs to see either that the beliefs aren’t valid or to clearly identify problems that clients can work on.

It is also important for counselors to understand the dynamics of these clients’ family systems, Carroll says. In some cases, family relationships have been broken or the client’s family members are struggling with addiction themselves. In either case, the client is faced with a lack of support and a potentially triggering environment, he says.

Carroll advises the use of genograms to explore family dynamics, looking in particular for toxic relationships or indications of a multigenerational history of substance abuse or mental illness. Through the use of genograms, “clients can see the roots [of their difficulties] and ask, ‘What can I create in my life right now to break the cycle?’” Carroll says.

Ashley, who also specializes in combat trauma, says that clients struggling against addiction also need to learn different ways to alter their consciousness and feel good. “People who have been addicted for a long time don’t know how to have fun,” he says. Ashley advises asking these clients about the activities that they used to enjoy and encouraging them to find or rediscover hobbies because they need alternatives to getting high.

“Exercise is good as long as they don’t overdo it,” he says. “Reading, bowling, going for a walk, art — it just depends. If you never had any experience [with hobbies], you have to try. If it doesn’t work, keep on trying.”

Ashley says clients also need to develop a plan to stay sober. These plans address elements such as how to stay away from situations or people that trigger or encourage substance use and abuse, how to handle stress and other emotions without opioids or other drugs, what to do when the urge to use strikes and how to occupy the time that previously went to scoring and taking drugs. Although counselors can assist clients with these plans, Ashley says it is equally important that they help clients find additional support through avenues such as group therapy, 12-step support meetings and other treatment programs if necessary.

Carroll agrees. “Counselors need to work closely with other health providers, medical professionals, social workers and school personnel,” he says. “It’s very imperative that you don’t work within a bubble. Get the individual the best help that you can.”

Necessary knowledge

Counselors can serve as a vital source of support for clients in recovery, but many practitioners have little or no training in addictions work. Bowden firmly believes that counselors need intensive training to work with those struggling with addictions.

Smith asserts that the grip of the opioid epidemic is so strong that all counselors must learn how to work with these clients. Likewise, counselors who specialize in substance abuse issues note that all practitioners will encounter clients who are struggling with addiction, even if addiction isn’t the presenting issue. Smith adds that clients may not reveal substance abuse problems right away, meaning that by the time the subject of addiction comes up, a therapeutic bond likely will have been established already with the counselor.

That is not to suggest, however, that the proper training isn’t important. Counselors should seek out additional courses on addictions work, either locally or online. Bowden and Ashley urge counselors to undergo supervision and to find a specialist with whom they can work. Counselors can also get involved with professional organizations such as the International Association of Addictions & Offender Counselors, a division of ACA.

“No matter what your practice is based on, most of your people are going to have addiction issues, whether obvious or not,” Ashley says. “So get to know people in the 12-step community. Look in the Yellow Pages or go online and Google ‘support groups,’ including options that aren’t [connected to] AA [Alcoholics Anonymous].”

When working with individuals who are battling addiction, Smith says, counselors also shouldn’t forget to simply call on the fundamentals of counseling. “A person needs to know that they are in safe company, with someone who is empathetic and who understands at least a little bit what they are going through and is willing to act as a guide.”




Larry Ashley, Kirk Bowden, Kevin Doyle and Carol Smith each served as panelists (along with Dr. Melinda Campopiano of the federal Substance Abuse and Mental Health Services Administration) at the congressional briefing on opioid abuse in April that was sponsored by ACA. For a report on that briefing, read the online exclusive, “‘We’re in danger of losing a generation,’” by Bethany Bray at CT Online (ct.counseling.org).




Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Opioid Use Disorder” by Rachel M. O’Neill
  • “Substance Abuse and Addictive Disorders” by Gerald A. Juhnke & Kathryn L. Henderson
  • “Chronic Pain Counseling” by Stephanie T. Burns

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “The Latest on Addiction Counseling, Co-Occurring has Replaced Dual-Diagnosis and Why is Crack so Addictive Anyway?” with Ford Brooks and Bill McHenry

ACA divisions

  • International Association of Addictions & Offender Counselors (iaaoc.org)




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

‘We’re in danger of losing a generation’

By Bethany Bray April 5, 2017

When a person is prescribed medicine by a doctor, the common assumption is that it’s best to take the dosage until it’s gone.

In most cases, that’s true. But with opioids, a class of powerful, addictive and frequently prescribed pain relievers, dependence on the drug can begin within five days. Yet doctors often prescribe a 30-day supply, said Carol Smith, a licensed professional counselor (LPC) who spoke at an April 4 congressional briefing on Capitol Hill that was sponsored by the American Counseling Association.

“By the end of the 30 days, [the opioid] is not addressing their pain anymore. It’s a vicious, vicious cycle,” said Smith, a professor of counseling at Marshall University in West Virginia and past president of the West Virginia Counseling Association.

Carol Smith, LPC and professor of counseling at Marshall University, speaks at ACA’s congressional briefing on opioids on April 4. At left is panelist Larry Ashley, LPC, LMSW and professor emeritus of counseling at the University of Nevada, Las Vegas. Photos by Bethany Bray/Counseling Today

Smith, a member of ACA, was speaking as part of a panel that focused on the realities of America’s opioid epidemic and how professional counselors are well-suited to help change that trajectory.

“What counselors bring to the table is essential to any response to this crisis,” said panelist and ACA member Kevin Doyle, a professor of counselor education at Longwood University who also has a private counseling practice in Charlottesville, Virginia. “This touches everyone. … Virtually no element of society is immune to this.”

The opioid class includes heroin as well as prescription pain relievers such as oxycodone, Vicodin and morphine. On average, 91 people across the U.S. die every day from opioid overdoses, according the U.S. Centers for Disease Control and Prevention. The amount of prescription opioids sold in the U.S. has nearly quadrupled since 1999; deaths from prescription opioids have more than quadrupled since 1999.

In the U.S., more than 650,000 opioid prescriptions are dispensed every day, said panelist and ACA member Kirk Bowden, an LPC who chairs the addiction and substance use disorder program at Rio Salado College in Arizona.

Opioids should be for acute, not chronic, pain, Bowden said. He also stressed the need for more training for medical professionals on the dangers of dispensing opioids.

For example, patients who have had oral surgery to remove their wisdom teeth are commonly prescribed a 30-day supply of opioids, when in most cases the drugs are only needed for a few days of pain relief, Bowden said. Patients then leave the remaining pills in their medicine cabinets, easily accessible to anyone in the household.

“[With opioids] if individuals use it, even as prescribed, over time the individual will become addicted,” said Bowden. “Something drastic needs to happen. … Over half a million people died between 2000 and 2015 from opioids. That’s like the city [the size] of Atlanta.”

“We’re in danger of losing a generation,” said Smith, who lives in West Virginia, a state with one of the highest opioid overdose rates in the U.S.

“As [Bowden] succinctly put it, we need to remember that this issue is not a singular crisis but a chronic problem that demands that we marshal all available resources to combat,” said Art Terrazas, ACA’s director of government affairs.

Panelists told congressional staff members attending the ACA-sponsored briefing that solutions need to include more addictions training for medical professionals, better access to care and support programs for people struggling with opioid addiction, and the inclusion of professional counselors in response efforts to the opioid crisis.

Kevin Doyle, LPC and professor of counselor education at Longwood University in Virginia speaks as Dr. Melinda Campopiano of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) looks on.

Counselors use a strengths-based approach and work to address the underlying reasons, such as past trauma, that individuals may turn to opioids to self-medicate, Smith explained.

“What counselors can bring to all of this is an attention to the whole person,” she said. “We come at it from a wellness perspective, and build on [a client’s] strengths. … We teach self-regulation and how to stay grounded in the here and now. We help people to know how to be sad in a healthy way, how to be angry in a healthy way and what to do with those emotions. Many people come to counseling and they can’t even identify that they’re angry. It’s been trained out of them by life experience.”

Counselors are uniquely skilled to support clients in their recovery goals – and in their possible relapses, Doyle added.

“We stick with them through the ups and downs,” he said. “We know that with treatment, recovery is possible.”




Watch a video of ACA’s Congressional briefing on opioids here: youtu.be/tqcEKMTqsaE


Download ACA’s infographic on opioids here: bit.ly/2p0ZJ0N



Dillon Harp of ACA’s Government Affairs team (far right) moderates the panel, from left to right Dr. Melinda Campopiano, Kevin Doyle, Kirk Bowden, Larry Ashley and Carol Smith.

About the panelists

Larry Ashley is a licensed professional counselor (LPC), licensed master social worker (LMSW) and professor emeritus of counseling at the University of Nevada, Las Vegas and addiction specialist at the University of Nevada, Reno School of Medicine. A U.S. Army veteran, he specializes in the treatment of military clients and issues related to combat trauma.

Kirk Bowden, an LPC and ACA fellow, is past president of NAADAC, the Association for Addiction Professionals, chair of the addiction and substance use disorder program at Rio Salado College, and consultant and subject matter expert for Ottawa University.

Dr. Melinda Campopiano is a physician and the chief medical officer of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration. She is board-certified in family medicine and addiction medicine.

Kevin Doyle, LPC, is a professor in the counselor education program at Longwood University and chair of the department of education and special education. He has served three terms on the Virginia Board of Counseling and runs a private practice in Charlottesville, Virginia.

Carol Smith, LPC, is a professor of counseling at Marshall University and coordinates Marshall’s Violence, Loss and Trauma Certificate of Advanced Studies program. She is past president of the West Virginia Counseling Association, a branch of ACA.






Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.





Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.







The culture of smoking in substance abuse recovery

By Bethany Bray December 12, 2016


Editor’s note: This online exclusive is a companion article to Counseling Today’s December feature “What counselors can do to help clients stop smoking,” http://wp.me/p2BxKN-4wQ


Less than half of substance abuse treatment centers in the United States have tobacco cessation programs, according to the U.S. Centers for Disease Control and Prevention. At the same time, the rate of smoking is much higher for those with mental illness or behavioral health problems than it is in the general population.

Despite all of the known health risks associated with smoking, many inpatient or rehabilitation facilities still give smoking breaks as a reward or as part of behavior modification programs, says Greg Harms, a licensed clinical professional counselor (LCPC), certified addictions specialist, and alcohol and drug counselor with a private practice in Chicago.

“There’s such a culture of smoking in mental illness treatment and substance abuse recovery. Historically, it was thought as helpful – an outlet that wasn’t their main addiction (alcohol, illegal zxqdghr2kiw-stas-svechnikovdrugs, etc.). This persists even to this day,” says Harms. “Doctors will still ignore the smoking issue. It just doesn’t get addressed. It’s really part of the culture at day programs, treatment programs and nursing homes.”

There’s a longstanding myth among helping professions – particularly those in the addiction and rehabilitation specialties – that smoking is “not as bad” as other addictions, says Ford Brooks, a licensed professional counselor (LPC) and professor at Shippensburg University of Pennsylvania.

This school of thought is exemplified in the fact that the co-founders of Alcoholics Anonymous, Bill Wilson and Bob Smith, both died of smoking-related illnesses (cancer and pneumonia), says Brooks.

“They were sober, but they were chronic smokers,” he says.

Practitioners often overlook a client’s smoking to focus on seemingly “bigger” problems, such as alcohol dependence, severe mental illness or illegal drug use, says Brooks. But smoking poses its own significant health risks, from lung disease to cancer, he notes.


Smoking quitlines: A lifeline for practitioners and clients

In the U.S., each of the 50 states, the District of Columbia, Puerto Rico and Guam have telephone “quitlines” that offer information and live support to callers who are looking to stop smoking.

American Counseling Association member Gary Tedeschi, clinical director of the California Smokers’ Helpline, urges counselors to call their state’s quitline themselves if they have questions or are looking for guidance to help a client through the quitting process.

Tedeschi, a national certified counselor and licensed psychologist, also encourages counselors to connect their clients with a local quitline. The service can offer more frequent and targeted contact for clients outside of counseling appointments. It also may help those who are less likely to open up in face-to-face meetings in a counselor’s office, Tedeschi adds.

Staff members who speak to quitline callers are well-trained and able to coach people through the quitting process, says Tedeschi. They also contact each caller again after the initial conversation to provide follow-up support.

Tedeschi says the phone counselors at his quitline call people several times – even if it’s just a brief check-in – during a person’s first week of quitting to reduce the chance of relapse.

“It’s a free service, it’s convenient and [it] helps people deal with the ambivalence they may feel about behavior change,” Tedeschi says of telephone quitlines. “Once they make initial contact, we will proactively follow up. We don’t have to wait for them to return [to a counseling office] or call back. They might be ambivalent about quitting or changing, but we’re not.”


Find out more at smokefree.gov or call 1-800-QUITNOW






Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.






Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

What counselors can do to help clients stop smoking

By Bethany Bray November 29, 2016

Nearly half of the cigarettes consumed in the United States are smoked by people dealing with a mental illness, according to the Substance Abuse and Mental Health Services Administration. The federal agency says that rates of smoking are disproportionately higher — a little more than double — among those diagnosed with mental illness than among the general population.

It is widely accepted that the nicotine in cigarettes is highly addictive, but people struggling with mental health issues often turn to cigarettes for reasons that go beyond their addictive qualities. For instance, many people smoke as a coping mechanism to deal with difficult feelings. In addition, despite their negative health effects, cigarettes are still largely viewed by society as an “acceptable” addiction in comparison with other substances.

The reality? “[Smoking] is a devastating addiction and a difficult one to quit,” says Gary Tedeschi, clinical director of the California Smokers’ Helpline and a member of the American Counseling Association. “This clientele [those with mental illness], in particular, need the encouragement and support to go forward [with quitting], and many of them want to, despite what people might think. … To let people continue to smoke because ‘it’s not as bad’ [as other addictions] is missing a really important chance to help someone get healthier.”

To drive home his point, Tedeschi points to a statistic from the 2014 release of The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General, which says that more than 480,000 people die annually in the United States from causes related to cigarette smoking. Close to half of the Americans who die from tobacco-related causes are people with mental illness or substance abuse disorders, Tedeschi says.

In Tedeschi’s view, the statistics connecting smoking to mental illness are “so obvious that it’s almost an ethical and moral responsibility to help this population quit.”

Part of a package

Ford Brooks, a licensed professional counselor (LPC) and professor at Shippensburg University of Pennsylvania, says he has never had a client walk in to therapy with a primary presentation of wanting to stop smoking.

Tobacco use “is always part of a package” that clients will bring to counseling, Brooks says. In his experience as an addictions counselor, smoking is often piled on top of a laundry list of other challenges that may include alcohol or drug addiction, depression, a marriage that is on the rocks, the loss of a job or financial trouble.

“They’re on the train to destruction, and their nicotine use, in their minds, is on the back end [in terms of importance]. … Is the smoking related to what their presenting issue is? Chances are it probably connects somehow. Don’t be afraid to bring it up,” advises Brooks, co-author of the book A Contemporary Approach to Substance Use Disorders and Addiction Counseling, which is published by ACA.

Tedeschi, a national certified counselor and licensed psychologist, notes that many people who call the California Smokers’ Helpline are struggling with comorbid conditions or mental illness in addition to tobacco use. The phone line is one in a system of “quitlines” operating in each of the 50 U.S. states, the District of Columbia, Puerto Rico and Guam.

For clients struggling with mental health issues, smoking may serve as a coping mechanism to deal with uncomfortable feelings or anxiety, Brooks says. Years ago, when smoking was still allowed in many indoor spaces, Brooks led group counseling in detox, outpatient and inpatient addictions facilities. “When powerful emotions would come up in group, [clients] would fire up cigarette after cigarette to deal with those feelings and quell anxiety,” he recalls.

With this in mind, counselors should help prepare clients for the irritability, anxiety and other uncomfortable feelings they are likely to experience when they attempt to stop smoking cigarettes. “Talk about what it will feel like to be really anxious and not smoke” and how they plan to handle those feelings, Brooks says. “… If a person has anxiety or depression and stops smoking, what initially happens is they could get more depressed or more anxious without nicotine to quell the emotion.”

The counselors interviewed for this article urge practitioners to ask every single client about their tobacco use during the intake process, no matter what the person’s presenting problem is. “If you’re helping them to get mentally and physically healthier, this [quitting smoking] is a very critical part of the overall wellness picture,” Tedeschi says.

Counselors shouldn’t be afraid to ask their clients whether they smoke, says Greg Harms, a licensed clinical professional counselor (LCPC), certified addictions specialist, and alcohol and drug counselor with a private practice in Chicago. “It can feel weird the first couple of times, especially if this is not your area of expertise,” says Harms, who does postdoctoral work at Diamond Headache Clinic in Chicago, an inpatient unit for people with chronic headaches. “A lot of times, clients have heard all the bad stuff about smoking. A lot of them, deep down, they know they’d be better off if they were to quit smoking. They may have failed so many times in the past that they’re discouraged. They might be hesitant to bring it up because this is a counselor and not the [medical] doctor. If you bring it up, more often than not, the client is going to engage with that. Even if they don’t, if it’s not the right time for them, you’ve planted that seed. … It might come to fruition down the road. I’d much rather plant that seed than not say anything at all.”

When Harms was a counseling graduate student, he completed an internship at the Anixter Center, a Chicago agency that serves clients with disabilities. While there, he worked as part of a grant-funded program for smoking cessation for people with disabilities that was spearheaded by the American Lung Association. He also presented a session titled “Integrating Smoking Cessation Treatment with Mental Health Services” at ACA’s 2013 Conference & Expo in Cincinnati.smoking

If a client doesn’t feel ready to begin the quitting process right away, the counselor can put the topic on the back burner to address again once the client has made progress on other presenting problems or has forged a stronger relationship with the practitioner. However, that shouldn’t mean that the topic is off the table completely, Harms says. A counselor should talk regularly with the client about quitting smoking, even if it’s only for a few minutes each session.

“Give them a little nugget of information [about quitting], and then you can focus on what they’re there for,” Harms says. “Help them find ways to deal with their presenting problem, then they’ll trust you. Once they’re in a better place, revisit [the idea of quitting]. We don’t have to address it and get their buy-in during the first session. It would be fantastic if that was the case, but it’s OK if it’s not. In most cases, time is on our side to develop the relationship, plant the seed and revisit it. If the client is not ready, we can harp on [quitting] all we want, [but] it won’t do anything.”

“You really have to take the client’s lead and go at the pace they’re willing,” Harms continues. “Don’t push. Respect their decision. Even if they’re not ready for [quitting], let them know that [you’re] there for them and respect their autonomy to make that decision.”

Positioned to help

Counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification, Tedeschi asserts. Motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and other models can be useful in helping clients stop smoking. But techniques from any therapy model that counselors are comfortable using can be adapted to help clients navigate the challenge of quitting, Tedeschi says, especially when combined appropriately with pharmacologic aids approved by the Food and Drug Administration.

“We’re in the business of helping people change. The principles that a counselor uses to help someone understand an issue and begin to make steps toward change apply to smoking cessation as well,” Tedeschi says. “Counselors help people understand their motivation to change and help them come up with a plan to change.”

Harms agrees, noting that in most cases, a counselor will have significantly more time with a client than a medical professional will. Instead of “hitting [the client] over the head” with the dangers of smoking, Harms says, a counselor can afford to focus on the positive, use a strengths-based approach and build on what the client wants to work toward rather than what he or she wants to avoid.

“We [counselors] are so strengths-based. It’s our natural inclination to tell the client, ‘Yes, you’re strong enough to do this,’ rather than [taking] a scare approach,” Harms says. “We can find their strength and have that unconditional positive regard for them, regardless of how long it’s taking. We have the patience to sit with a client as they’re going through [quitting]. We can build that relationship and be a resource.”

Start small

Tedeschi recommends that counselors use the “five A’s” to discuss smoking with clients. In this approach, a practitioner should:

  • Ask each client about his or her tobacco use
  • Advise all tobacco users to quit
  • Assess whether the client is ready to quit
  • Assist the client with a quit plan
  • Arrange follow-up contact to mitigate relapse

Each of these steps is important, but providing support and follow-up as the client begins to quit is particularly critical, Tedeschi says.

“The first week of quitting is the hardest. If [a counselor] waits for a week to talk to the client, you could lose about 60 percent of people back to relapse,” he says. “If someone is able to quit for two weeks, their risk of relapse drops dramatically.”

If clients resist the idea of quitting or do not feel ready to quit entirely, Tedeschi suggests that counselors work with them to stop smoking for one day or even just an afternoon. During this time, have clients monitor how they felt: How was their anxiety level? What were their cravings like? This technique can introduce the idea of stopping and prepare clients for the quitting process, he says.

Brooks recommends using motivational interviewing to help clients make the life change to quit smoking. “Nicotine is a drug, and it’s no different than if [clients] were to say they want to stop drinking. Work with their motivation to identify what they can possibly do for that,” he says.

Part of the quitting process involves clients going through an identity shift, Tedeschi notes. Clients can be behaving as nonsmokers — abstaining from cigarettes — long before they make the mental leap that they are no longer smokers, he says. It is important for clients to make that mental shift from “a smoker who is not smoking” to a “nonsmoker,” Tedeschi says. Counselors need to work with these clients to identify as and accept the nonsmoker label. “As long as someone calls [himself or herself] a smoker, they will be open to turning back to cigarettes,” he explains.

Kicking the habit

Counselors can use the following tips and techniques to better equip clients to meet the challenge to stop smoking.

Set a quit date. This is an important step, but one that clients must take the lead on and choose for themselves, Tedeschi says. Research shows that simply cutting back without setting a quit date isn’t very effective, he adds. The behavioral patterns that often accompany smoking (for example, smoking after eating or taking smoke breaks at work) make it very hard to keep tobacco use at a low level. Setting a quit date creates accountability and is a “sign of seriousness,” he says. At the same time, be flexible. “For some people, it’s just too hard to think about [sticking to a quit date],” Tedeschi says. “For some — especially those who are struggling with other substances — they need to take one day at a time.”

Be aware of psychotropic medications. Counselors should be aware that if clients are taking prescription medicines for anxiety, depression, bipolar disorder or other mental illnesses, their dosages might need to be adjusted as they quit smoking. Nicotine is a stimulant, so it speeds up a person’s metabolism. This means a person who smokes will burn through psychotropic medications faster than someone who doesn’t smoke, Harms explains. Counselors should be certain to talk this through with clients and work with their doctors to modify their dosages, he says. “This is especially noticeable with mood stabilizers. It’s acute with bipolar disorder,” Harms says.

The same holds true with caffeine, Tedeschi notes. After they quit smoking, clients may notice that they get jittery from caffeine and may need to cut back on their coffee intake.

Use cognitive strategies. Counselors can help clients create a list of personal reasons why they want to stop smoking — beyond the health implications, Tedeschi says. The list doesn’t need to be long, but the reasons need to be compelling and motivating enough to carry clients through a nicotine craving. For example, one of Tedeschi’s clients wanted to quit because his young grandson asked him to. As a reminder, the client kept a toy car that belonged to his grandson in his pocket. “When he had a craving [for a cigarette], he would pull [the toy car] out of his pocket, look at it, hold it and squeeze it,” Tedeschi says. “It helped.”

Turn over a new leaf. As they quit smoking, encourage clients to organize, clean and purge their homes and cars of smoking-related materials such as ashtrays, advises ACA member Pari Sharif, an LPC with a practice in Franklin Lakes, New Jersey. That action will help clients turn a new page mentally and start fresh, she says. Sharif also encourages clients to air out their homes and clean their closets so their clothes and furniture no longer smell like smoke.

On a similar note, if clients have a certain mug that they always use to drink coffee while smoking, Harms suggests that they get a new mug. Or if they always stopped at a certain gas station to buy cigarettes, he suggests that they now change where they buy gas.

When cravings strike, breathe. Sharif, a certified tobacco treatment specialist, introduces breathing techniques to all of her smoking cessation clients. She asks these clients to take measured breaths for roughly two minutes, inhaling while slowly counting to four, then exhaling for four counts.

“Instead of the reflex habit to grab a cigarette, take a moment to stop and ask why. Be more in control of yourself and your mind,” she tells clients. “Pause to do breathing and body scanning from head to toe. Ask yourself, ‘What am I doing? Why do I need this [cigarette] to calm down?’ … [Through breathing exercises,] your breath becomes deeper and deeper. Close your eyes. Your body starts relaxing and your anxiety level goes down.”

Sharif also recommends that clients download a meditation app for their smartphones and use a journal to record how they’re feeling when cigarette cravings strike. This helps them log and identify which situations and emotions are triggering their need for nicotine,
she explains.

Get to the root of it. Asking clients about the circumstances that first caused them to start smoking can help in identifying what triggers their nicotine use and the bigger issues that may need to be addressed through counseling, Sharif says. In some cases, a specific traumatic event or stressor caused the person to start smoking. In other instances, it was a learned behavior because everyone in the household smoked as the client was growing up. “Find out when they started smoking and why,” Sharif says. “Gradually, when they become more aware of themselves, they quit.”

Change social patterns. Cigarettes are often used as a coping mechanism when people experience anxiety in social situations, Harms says, so clients may need to focus on social skills as they start the process of quitting smoking.

“[Cigarettes] are their way to socialize and get out and meet people. If you have social anxiety, you can still go up to someone and ask for a cigarette or ask for a light. It’s programmed socialization,” Harms explains. “It gives you an excuse to be close to people, feel more sociable. If you take away their cigarettes, you’ve got to replace that.”

Brooks agrees, noting that clients who smoke likely have friends who are also smokers. For example, he says, it is not uncommon to see people smoking and talking together outside of Alcoholics Anonymous meetings. Counselors can help clients prepare to avoid situations where smoking is expected and practice asking people not to smoke around them, Brooks says. Counselors can also support clients in creating social networks of people who don’t smoke, including support groups for ex-smokers, he adds.

Break behavioral habits. Similarly, Brooks says, counselors can help clients change the behavioral habits they connect to smoking, such as starting the morning by reading the paper, drinking coffee and smoking a cigarette. Counselors can suggest activities and new rituals to replace the old ones, such as taking a daily walk, he says.

Harms encourages clients to replace their former smoke breaks with “clean air breaks.” They can still take their normal time outside, but instead of smoking, he suggests that they walk around the block, sit and read a book, eat an apple or use their smartphones outdoors. If they had a favorite smoking spot outside, he urges them to find a new place to go instead.

Find comforting substitutes. “The whole ritual of lighting up a cigarette — tapping the pack to pull out a cigarette and flicking the lighter — the behaviors that go with [smoking] can be very comforting,” Harms says. “Sometimes that’s what’s so hard to break — the behaviors that go with it.”

Tedeschi recommends that counselors work with clients to have comforting alternatives ready to go even before the clients attempt to quit smoking. It is hard for people to figure out alternatives in the heat of the moment when a craving strikes, he explains. Tedeschi offers several possible substitutes for consideration: sugar-free gum, beef jerky, cinnamon sticks and even drinking straws cut into cigarette-sized lengths through which clients can inhale and exhale.

If clients are comforted by having something in their hands, Brooks suggests keeping a pen, stress ball or prayer beads nearby. Staying hydrated and carrying a water bottle can also help these clients, Tedeschi adds. Most of all, counselors should work toward the idea of replenishment and filling in where clients feel they are losing something, he says.

Don’t dismiss pharmacotherapy. A wide variety of quitting aids are available, from nicotine patches, lozenges and gum, to prescription pills such as Chantix. The counselors interviewed for this article agree that these stop-smoking aids can be helpful when used alongside counseling. However, Tedeschi says, counselors should work with their clients’ physicians when such medications are being used, or make sure that clients are talking with their physicians. Counselors should also be aware of the potential side affects that these medications can have, such as aggressive behavior.

Brooks notes that none of these options is a magic solution to quit smoking. For example, nicotine gum and other medications can be prohibitively expensive, and some clients can continue to smoke even while using nicotine patches or gum. As for electronic cigarettes, Sharif and Harms agree that they are not a recommended alternative. Electronic cigarettes are carcinogenic, addictive and mimic the “puffing” behavior of regular smoking, Harms notes.

Connect clients with other supports. Counselors should equip clients with resources they can turn to outside of counseling sessions, such as local support groups for ex-smokers or the phone number for their state’s tobacco quitline, Brooks suggests. Nicotine Anonymous (nicotine-anonymous.org) is an ideal resource for clients who are trying to stop smoking, Brooks says. The 12-step method at Alcoholics Anonymous (AA) can also be applied to tobacco use for clients who attend AA meetings already or who don’t have a Nicotine Anonymous support group in their local area, he adds.

Sharif suggests that counselors keep brochures and other information about quitting smoking alongside the materials they might have about depression or suicide prevention in their offices or waiting rooms. It is better for counselors to distribute information that they have vetted themselves rather than having clients search the internet for information on their own, she notes.


Try and try again

On average, it takes a smoker 10-12 attempts to fully quit cigarettes, according to Tedeschi. For that reason, it is imperative that practitioners not give up on clients after their first, second or even 10th try, he stresses.

Quitting smoking is hard, Tedeschi acknowledges, but possible with perseverance. “Don’t be discouraged as a clinician if your client relapses. [Quitting] is definitely not a one-time event; it’s a process. … Relapse prevention is important, but it’s equally important to be ready for the relapse,” he says. “One of the best things a counselor can give a client is that reassurance. Any attempt to quit for any length of time is a success rather than a failure. That’s just the reality of this addiction. As long as they keep trying, they’ll get there. The only failure is to stop trying. The most important message a counselor can give a client is to never give up.”




Statistics: Smoking and mental health

  • Roughly 50 percent of people with behavioral health disorders smoke, compared with 23 percent of the general population.
  • People with mental illnesses and addictions smoke half of all cigarettes consumed in the U.S. and are only half as likely as other smokers to quit.
  • Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.
  • Approximately 30-35 percent of the behavioral health care workforce smokes (versus 1.7 percent of primary care physicians).

— Source: U.S. Substance Abuse and Mental Health Administration (see bit.ly/1sEx97a)








Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Getting unstuck

By David Flack March 28, 2016

Andrew never knew his father. At age 4, he witnessed the death of his mother from an overdose. She was heroin dependent, and they were living in a car at the time. After her death, Andrew entered the foster care system. Between the ages of 4 and 15, he experienced more than a dozen different placements. Not surprisingly, with each move, his behavior became increasingly problematic.

At age 9, Andrew started drinking alcohol. By age 11, he was using alcohol and marijuana regularly. He discovered meth as a 13-year-old and went to inpatient care for the first time. He ran away after four days. When he was 15, he ran from the group home where he was living.

When Andrew entered treatment at age 16, he was on probation and had just moved into a transitional living program after several months on the streets. When he started treatment, he met Branding-Images_Unstuckthe criteria for multiple substance use disorders. He also had pre-existing mental health diagnoses that included posttraumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder, conduct disorder and major depressive disorder. At that time, Andrew said he had no interest in stopping his substance use because “that’s not a problem for me.”

In his treatment journal, Andrew wrote, “Lots of times I feel like I’m living in some kind of black hole. I’m alone, but not really, because everything’s there, because I just can’t escape it no matter what I try. It’s black there, because that’s what black holes are, right? But black is really all the colors at once, every single one of them. And that’s too many damned colors if you ask me.”

Understanding the stuckness

Very few teenagers enter substance abuse treatment by choice. They show up due to legal mandates, school requirements, family pressure or other external reasons. Often they see treatment as the least bad choice — only slightly better than detention, suspension or homelessness. Like Andrew, these teens often appear unwilling or unable to do things differently, even though their current behaviors are clearly causing problems. In other words, they’re stuck.

I propose that our primary task as counselors is to help these teens get unstuck — not behave better, fulfill mandates or even stop using substances. We can hope those other things happen. I certainly do. However, it seems to me that those changes can occur only when an individual gets unstuck.

When helping teens get unstuck, we need to maintain a developmental perspective as counselors. Various developmental models exist, with most including a progression of stages that individuals move through, and each stage featuring specific tasks to be accomplished. The primary stage-specific tasks for adolescence are generally considered to be developing identity and establishing autonomy. As part of establishing autonomy, it is normal for adolescents to question, rebel against and ultimately reject the plans of authority figures, including the most well-intended plans of professional helpers.

Sometimes, those well-intended plans lead to reactance, which is a tendency to resist influences perceived as a threat to one’s autonomy. Many adolescent treatment programs are designed in ways likely to exacerbate reactance. We tell adolescents what, when, why and how. In residential programs, we restrict personal items. In wilderness programs, we often take away everything. Then we wonder why participants are unsuccessful. Worse, we blame them — declaring them in denial, resistant to treatment, unwilling to engage or simply noncompliant. Instead of helping, we’ve increased their stuckness.

Reactance can be exacerbated by what I think of as developmental debt. Most developmental theories state that if a person doesn’t successfully complete the tasks for a specific stage, then he or she remains in that stage. It seems to me that this might not be accurate. Instead, sociocultural and biological factors keep pushing individuals forward, even when tasks at another stage are unresolved or only partially completed.

With every push forward, an individual becomes less likely to complete the next stage. This leads to an ever-growing developmental debt. Much like with a credit card that’s never fully paid off, the person not only will always have a balance due, but he or she will get further behind each month.

With this developmental perspective in mind, I propose five strategies for fostering change with teenagers who have co-occurring disorders. Inspired by motivational interviewing, stages of change, narrative approaches and existential psychotherapy, I have found these strategies useful for helping this population to overcome rigid thinking, get unstuck and start moving forward.

Slow down

Traditionally, drug treatment programs have assumed that anyone entering services is ready to get and stay clean. This simply isn’t true. Change is a process, not an event. When we slow down, we’re able to help participants move through that process. Developed by James Prochaska, John Norcross and Carlo DiClemente, the stages of change is an evidence-based transtheoretical model that identifies five steps in the process of change:

  • Precontemplation: The person doesn’t believe he or she has any problems related to the target behavior, so the person sees no reason to make changes. To help participants in this stage, we can focus on building a therapeutic alliance, validate the participant’s lack of desire to change and provide objective information.
  • Contemplation: The person is considering the possibility that a problem might exist but hasn’t yet decided if change is necessary. To help participants in this stage, we can explore the pros and cons of continuing to use substances, gently identify contradictions, help make links between substance use and mental health challenges, and provide opportunities to imagine or experience alternatives.
  • Preparation: The person has identified a problem related to the target behavior and is deciding what to do next. To help participants in this stage, we can encourage small initial steps or experiments, continue to explore and solidify motivation for change, and help eliminate obstacles to change.
  • Action: The person has decided to change the target behavior, has developed a plan and is now putting that plan into action. To help participants in this stage, we can explore ways to implement change, provide support, build self-efficacy and remain solution focused.
  • Maintenance: When the new behavior has become habit, the person has entered this stage. I propose that six months of sobriety is a good milestone for this. To help participants in this stage, we can provide ongoing support, continue to explore real or perceived obstacles and foster resiliency.

In addition to these five stages, there’s Recycle, which occurs when a participant reverts to behaviors from an earlier stage. When a participant recycles, many helpers blame the person’s lack of skills, situational factors or unwillingness to change. Extenuating circumstances may certainly be present, but it seems to me that recycles occur because we push participants into the action stage too quickly. As such, recycles are potent reminders that we should slow down and revisit earlier stages, looking for unfinished or overlooked business.

Identify their motivators

Teens often enter services believing that they’re free of problems or that their only problem is something external. It may not seem like success to some, but the change process has begun when teens report treatment as the least bad option, state that their only problem is that others think there’s a problem or make similar comments. These may not be the motivators we desire for participants, but change requires meeting them where they are at, not where we want them to be.

We can help clients discover and deepen their motivators by using the “Five R’s” from William Miller and Stephen Rollnick’s motivational interviewing:

  • Relevance: Why is change important?
  • Risks: What are the risks of changing? What are the risks of not changing?
  • Rewards: What will you gain from change?
  • Roadblocks: What are the obstacles to change?
  • Repetition: Review these elements at each session.

Sometimes, to help participants solidify their motivators for change, we need to assist them in developing problem-recognition skills. We can do this by exploring what defines a problem; nurturing mindfulness; and creating an inclusive, nonjudgmental treatment environment.

Approaches from narrative therapy can also be helpful. Teens with co-occurring disorders typically enter treatment with problem-saturated stories. These tales of stuckness have become the defining stories for their lives. Help them discover new stories and further increase problem-recognition skills by:

  • Externalizing the problem: Instead of “having” a problem or “being” a problem, assist participants to view problems as existing outside themselves. This helps remove pressures rooted in blame, shame and defensiveness. Take
    this even further by encouraging participants to think of problems as characters in their stories.
  • Seeking exceptions: We build and sustain problem-saturated stories by ignoring times when the problem wasn’t in control. Seeking exceptions involves assisting participants to discover those ignored times. These exceptions hold
    the keys to change, so explore them in great detail.
  • Reauthoring stories: Once exceptions have been discovered, participants can start reauthoring their problem-saturated stories. Reauthoring gives them the opportunity to create new, more empowering stories with plots that focus on moving forward.

Some teenagers are so stuck that they’re unable to identify any exceptions to their problem-saturated stories. In these cases, it can be useful for counselors to add a fourth approach to those cited previously: creating exceptions. One way for these teens to break the cycle of stuckness is to try something new. I’ve had participants explore belly dancing, glass blowing, rock climbing, rugby, hand drumming and much more.

Expect ambivalence

As I’ve noted, the change process has begun when a teen’s thinking moves from “I don’t have a problem” to “My only problem is that other people think there’s a problem.” When this occurs, the participant has moved into the contemplation stage of change. This stage is about ambivalence, which can be defined as simultaneously believing two seemingly contradictory ideas.

Ambivalence is common for all teenagers, who desire the privileges of adulthood while retaining the comforts of childhood. In the case of substance-using teens, there is often another, more complex layer — wanting to fix their problem while continuing to use. Andrew described this ambivalence well: “Using has really messed up my life, but I don’t think I’ll ever stop. When I’m high, the bad feelings go away. I don’t think about the past, and I don’t care about the future. For a little while, my brain shuts up and I can pretend everything’s OK.”

Some professional helpers focus solely on the reasons to stop using, perhaps believing that any discussion about the possible benefits of drug use will be seen as an endorsement. This simply isn’t true. Helping youth such as Andrew get unstuck requires a sincere, nonjudgmental exploration of both the pros and the cons of substance use. Here are a few other ideas for resolving ambivalence:

  • Normalize the process. Change is hard. It conflicts with deeply ingrained behavioral patterns and neural pathways. It requires us to ignore the stories we tell about who and what we are. It requires us to face the unknown. Because change is hard, we’d rather stick to the known, even when it is not effective or useful anymore. Helping participants realize that ambivalence is common can be essential to helping them get unstuck.
  • Explore the risks of changing. High-risk behavior is common in the lives of many teens with co-occurring disorders. Paradoxically, these teens are often risk avoidant. As Prochaska, Norcross and DiClemente noted in 1994, change “threatens our very identity and asks us to relinquish our way of being.” This is dangerous stuff for anyone, but for stuck teens, it can feel especially risky. Helping them make lasting change requires exploring the risks involved.
  • Foster self-efficacy. Albert Bandura wrote that self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations.” In other words, it is a person’s belief in his or her ability to succeed. Teens with low self-efficacy avoid challenging tasks, focus on negative outcomes and quickly lose confidence in their ability to be successful. They have very little interest in attempting to change.
  • Disrupt rigid thinking habits. Teens with co-occurring disorders typically exhibit all-or-nothing thinking, catastrophize, deny having problems and blame others. These rigid thinking patterns reinforce their ambivalence. Resolving ambivalence requires them to think between the extremes. Traditional cognitive behavioral approaches identify these thinking patterns as irrational, erroneous and maladaptive. I prefer the term thinking habits, because habits can be changed.
  • Address existential concerns. Irvin Yalom identified four “givens” that define an existential perspective to psychotherapy: death, meaninglessness, freedom and isolation. Professional helpers sometimes shy away from these existential concerns, especially when working with adolescents. However, these givens are very much present in the lives of teens and can contribute significantly to both stuckness and ambivalence. Acknowledge these givens and explore them with participants.

Become trauma-informed

The Substance Abuse and Mental Health Services Administration defines trauma-informed care as “an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives.” Trauma-informed care includes the use of carefully developed approaches that reduce the likelihood of retraumatizing participants while integrating safety, trustworthiness, choice, collaboration and connection into all interactions.

Studies show that as many as 75 percent of teens in treatment for substance use disorders have experienced some form of traumatic stress. This occurs when an individual is exposed to a potentially traumatizing event or situation that overwhelms his or her ability to cope. Traumatic stress can be caused by a one-time experience or complex trauma, which can be defined as the experience of multiple traumatic events. Traumatic stress can lead to PTSD, a severe anxiety disorder that develops after exposure to traumatic stress. PTSD is a clinical diagnosis that requires the presence of specific symptoms, such as nightmares about the traumatic event, avoidance of stimuli associated with the event, increased arousal and hypervigilance. Regardless of whether they meet the diagnostic threshold for PTSD, teen trauma survivors often exhibit the following:

  • Hyperarousal: Survivors can become extremely vigilant about their surroundings and often experience high levels of anxiety, which leads to sleep problems, trouble concentrating, feeling constantly on guard or being easily startled.
  • Intrusion: Memories, flashbacks, and nightmares can continue long after the original traumatic exposure. Additionally, survivors sometimes unintentionally reenact aspects of the trauma. For example, teen survivors often engage in highly risky behaviors.
  • Constriction: Attempts to avoid intrusion frequently result in survivors withdrawing from the world both physically and emotionally. Agoraphobia, substance use, limited social interactions and dissociation are a few examples of constriction.

When an individual has both a substance use disorder and traumatic stress, we usually assume that the trauma led to using the substance. However, substance use often leads to trauma exposure — or further exposure. In addition, pre-existing mental health challenges and a variety of other factors can increase the likelihood of trauma exposure. Whether trauma leads to drug use, drug use leads to trauma or a more complex scenario is present, substance-abusing survivors often find themselves perpetually stuck.

Even though risky behavior is evident in the lives of most substance-abusing teens, and especially those with trauma histories, these youth are frequently risk adverse, with their risky behaviors serving as ineffective attempts to avoid risk or distractions from their past trauma. Some adolescent survivors are so obsessed with safety that they resort to substances and other maladaptive methods in an effort to find it. Still other teens lead lives so constricted that they barely participate in life. According to Judith Herman, in all these cases, trauma has “cast the victim into a state of existential crisis” in which all choices likely lead to even further stuckness.

Create connectedness

Edward Hallowell wrote that connectedness “is a sense of being a part of something larger than oneself. It is a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone. … Connectedness is my word for the force that urges us to ally, to affiliate, to enter into mutual relationships, to take strength and to grow through cooperative behavior.”

For teens with co-occurring disorders, this sense of connectedness is typically missing. I believe that isolation exacerbates all life problems, so I strongly propose that the first step toward ensuring a valuable therapeutic experience is helping participants move toward increased connectedness. In clinical settings, we can focus on two types of connectedness: group cohesion and therapeutic alliance.

Group cohesion: It seems to me that groups should be part of the treatment plan for any teen with co-occurring disorders. That said, for change to happen in groups, a strong sense of cohesion is essential. We can help achieve group cohesion by remembering this simple formula: Cohesion = Shared Fun + Safety.

When working in groups, it is essential that we create safe spaces. This includes physical, emotional and social safety. We can create a sense of safety by modeling what we expect. That means being consistent and reliable, treating participants and co-facilitators in a welcoming manner and ensuring that groups are fully inclusive.

Some treatment approaches seem to assume that participants are fragile, hopelessly damaged or completely dysregulated. Fun activities and laughter have no place is such approaches. That’s a shame. Shared fun activities build connectedness between group members and provide valuable opportunities to practice interpersonal skills. In addition, the use of fun and games helps alter negative preconceived notions of treatment, provides entry points for less verbal participants and helps teens reauthor their stories to include a world where laughter is the norm.

Therapeutic alliance: Numerous studies show that a strong therapeutic alliance is the most important indicator of positive outcomes when working with teens. When we take time to foster a strong alliance by genuinely embracing our participants’ real motivators, we stop being an adversary and become an ally. This allows us to gently challenge the ambivalence, thinking habits and other roadblocks that keep participants stuck.

Edward Bordin wrote that a strong therapeutic alliance is composed of three elements: a positive bond between the therapist and participant, agreement regarding the tasks of treatment and agreement about the goals of treatment. In other words, there is congruence between the participant and the therapist. It seems to me that there also exists a need for transparency. Here are a few ideas for this:

  • Explain what you’re doing as a counselor. Take time to explain the theory behind your therapeutic approaches. In addition, explain to the teen what you hope to achieve by asking a particular question or assigning a specific homework task. This not only increases transparency but also improves buy-in.
  • Remember that relationships are reciprocal. We expect participants to be honest. They should get the same from us. Don’t disclose excessive amounts of personal information, but do answer questions that have been sincerely asked. Be genuine and model openness.
  • Use concurrent documentation. Before ending individual sessions, write your progress note. Then have the participant read the progress note and write his or her own summary of the session. This may seem a bit clumsy at first, but in my experience, most participants quickly embrace the process.

Addiction as an attachment disorder 

Substance abuse specialists familiar with attachment theory invariably report an inverse relationship between substance use disorders and healthy interpersonal attachments. In traditional treatment, unhealthy interpersonal attachments are generally considered the result of addiction. There is no doubt that heavy substance abuse is likely to exert a negative influence on relationships. However, there is mounting evidence that insecure attachment styles are risk factors for problematic substance use.

There are two basic concepts that are important for us to consider. First, if we don’t have opportunities to observe caregivers engaging in effective emotional regulation, we may resort to substances in an effort to manage uncomfortable feelings. Second, if we don’t connect to other people in meaningful, emotionally satisfying ways, we will find something else to fill that void.

Andrew referred to this void as a black hole made of all colors and tried to fill it with alcohol, drugs and significant acting-out behaviors. Other teens try to fill their voids with gangs, gambling, food, sex or video games. When we slow down and meet participants where they are at, we are able to help them get unstuck and start the change process so that they can see all the colors, not just black.




Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

David Flack is a licensed mental health counselor, chemical dependency professional and child mental health specialist. He lives in the Seattle area and has worked for the past dozen years exclusively with teenagers who have co-occurring disorders. He has special interests in the comorbidity of substance use and trauma in adolescents, the use of experiential learning in clinical settings and the unique challenges faced by LGBTQ teens. Contact him at david@davidflack.com.

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